UNIT COSTS OF HEALTH & SOCIAL CARE

Transcription

1 UNIT COSTS OF HEALTH & SOCIAL CARE 2009 COMPILED BY Lesley Curtis PSSRU

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3 Unit Costs of Health and Social Care 2009 compiled by Lesley Curtis

4 University of Kent, 2009, 2010 Second printing, August 2010, incorporating corrections and amendments up to 010 as detailed at Published by: Personal Social Services Research Unit Cornwallis Building The University of Kent Canterbury Kent CT2 7NF Telephone: Fax: PSSRU website: The PSSRU also has branches at: London School of Economics and Political Science Department of Social Policy and Administration Houghton Street London WC2A 2AE Telephone: The University of Manchester Faculty of Medicine, Dentistry and Nursing First Floor, Dover Street Building Oxford Road Manchester M13 9PL Telephone: If you would like additional copies of this report, please contact the PSSRU librarian in Canterbury (telephone: ; This work was undertaken by the PSSRU, which receives support from the Department of Health. The views expressed in this publication are those of the authors and not necessarily of the Department of Health. [rev. 1] ISSN: X ISBN:

5 Contents Foreword....vii Preface...1 Lesley Curtis Guest Editorial...7 Ian Shemilt and Miranda Mugford Estimating unit costs for Direct Payments Support Organisations...15 Vanessa Davey, Francesco d Amico and Martin Knapp The National Dementia Strategy: potential costs and impacts Jennifer Beecham SCIE s work on economics and the importance of informal care...27 Jennifer Francis and David McDaid I. SERVICES 1. Services for older people 1.1 Private nursing homes for older people Private residential care for older people Voluntary residential care for older people Local authority residential care for older people Nursing-Led Inpatient Unit (NLIU) for intermediate care Local authority day care for older people Voluntary day care for older people Local authority sheltered housing for older people Housing association sheltered housing for older people Local authority very sheltered housing for older people Housing association very sheltered housing for older people Community care package: very low cost Community care package: low cost Community care package: median cost Community care package: high cost Community care package: very high cost... 52

6 iv Unit Costs of Health and Social Care Services for people with mental health problems 2.1 Local authority residential care (staffed hostel) for people with mental health problems Local authority residential care (group home) for people with mental health problems Voluntary sector residential care (staffed hostel) for people with mental health problems Voluntary sector residential care (on-call staff) for people with mental health problems Private sector residential care (staffed hostel) for people with mental health problems Acute NHS hospital services for people with mental health problems Long-stay NHS hospital services for people with mental health problems NHS psychiatric intensive care unit (PICU) NHS Trust day care for people with mental health problems Local authority social services day care for people with mental health problems Voluntary/non profit-organisations providing day care for people with mental health problems Sheltered work schemes Cognitive behaviour therapy (CBT) Counselling services in primary medical care Services for people who misuse drugs/alcohol 3.1 Voluntary sector residential rehabilitation for people who misuse drugs/alcohol NHS inpatient treatment for people who misuse drugs/alcohol Cost of maintaining a drugs misuser on a methadone treatment programme Alcohol health worker, Accident & Emergency Services for people with learning disabilities 4.1 Group homes for people with learning disabilities Village communities Fully-staffed living settings Supported living schemes Semi-independent living settings Local authority day care for people with learning disabilities Voluntary sector activity-based respite care for people with learning disabilities Services for younger adults with physical and sensory impairments 5.1 High dependency care home for younger adults with physical and sensory impairments Residential home for younger adults with physical and sensory impairments Special needs flats for younger adults with physical and sensory impairments Rehabilitation day centre for younger adults with brain injury Hospital and other services 6.1 Hospital costs NHS wheelchairs Local authority equipment and adaptations Training costs of health service professionals Rapid Response Service Community rehabilitation unit...98

7 Unit Costs of Health and Social Care 2009 v 6.7 Hospital-based rehabilitation care scheme Intermediate care based in residential homes Expert Patients Programme Unpaid care II. COMMUNITY-BASED HEALTH CARE STAFF 7. Scientific and professional 7.1 Community physiotherapist NHS community occupational therapist Community speech and language therapist Community chiropodist/podiatrist Clinical psychologist Community pharmacist Nurses and doctors 8.1 Community nurse (includes district nursing sister, district nurse) Nurse (mental health) Health visitor Nurse specialist (community) Clinical support worker nursing (community) Nurse (GP practice) Nurse advanced (includes lead specialist, clinical nurse specialist, senior specialist) a General practitioner cost elements b General practitioner unit costs c General practitioner commentary III. COMMUNITY-BASED SOCIAL CARE 9. Social care staff 9.1 Social work team leader Social worker (adult) Social work assistant Approved social worker mental health Local authority home care worker Community occupational therapist (local authority) Intensive case management for older people Family support worker Health and social care teams 10.1 NHS community mental health team (CMHT) worker for older people (OP) with mental health problems Community mental health team for adults with mental health problems Crisis resolution teams for adults with mental health problems Assertive Outreach Teams for adults with mental health problems Early intervention teams for adults with mental health problems Generic single disciplinary CAMHS teams Generic multidisciplinary CAMHS teams Dedicated CAMHS teams Targeted CAMHS teams

8 vi Unit Costs of Health and Social Care 2009 IV. HOSPITAL-BASED HEALTH CARE STAFF 11. Scientific and professional 11.1 Hospital physiotherapist Hospital occupational therapist Hospital speech and language therapist Dietitian Radiographer Hospital pharmacist Clinical support worker higher level nursing (hospital) Nurses 12.1 Nurse team manager (includes ward managers, sisters and clinical managers) Nurse team leader (includes deputy ward/unit manager, ward team leader, senior staff nurse) Nurse, day ward (includes staff nurse, registered nurse, registered practitioner) Nurse, 24-hour ward (includes staff nurse, registered nurse, registered practitioner) Clinical support worker (hospital) Doctors 13.1 Foundation house officer Foundation house officer Registrar group Associate specialist Consultant: medical Consultant: surgical Consultant: psychiatric V. SOURCES OF INFORMATION Inflation indices Agenda for Change pay bands Glossary References Index of References List of useful sources List of items from previous volumes not included in this volume Index of Services...204

9 Foreword This is the seventeenth volume in a series of volumes from a Department of Health-funded programme of work based at the Personal Social Services Research Unit at the University of Kent. To a greater or lesser degree, the costs reported always reflect work in progress, as the intention is to refine and improve estimates wherever possible, drawing on a wide variety of sources. The aim is to provide information that is detailed and comprehensive, and to improve unit cost estimates over time, drawing on material as it becomes available, including ongoing and specially commissioned research, and quoting sources and assumptions so users can adapt the information for their own purposes. In putting the volume together, there are a large number of individuals who have provided direct input in the form of data, permission to use material, and background information and advice. Grateful thanks are extended to Ann Netten and Jennifer Beecham who have been an invaluable source of support in the preparation of this report. I would also like to extend a special thanks to Glen Harrison and Nick Brawn for taking expert charge of the design and typesetting. Thanks are also due to Jacques Ashley, Sarah Byford, Adriana Castelli, Vanessa Davey, Jane Dennett and Keith Derbyshire. Thanks also to Ben Hickman, Sarah Horne, Martin Knapp, David Lloyd, David McDaid, Miranda Mugford, Neil Parkinson, Stephen Richards, Katharine Robbins, Tim Roast, Renee Romeo, Ian Shemilt, David Stevens, Rob Stones, Marian Taylor, Helen Weatherly, Richard Wistow and Raphael Wittenberg. If you are aware of other sources of information which can be used to improve our estimates, notice errors or have any other comments, please contact Lesley Curtis, telephone Many figures in this report have been rounded and therefore occasionally it may appear that the totals do not add up. This report may be downloaded from our website:

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11 Preface Lesley Curtis In this seventeenth volume of the Unit Costs report, we have included a guest editorial followed by three short articles. Here we introduce these and also identify improvements, new information and any other changes that have been made this year. All data sources have been reviewed to ensure that the information is as up-to-date as possible, and information about any schemata which have been included in previous volumes, but excluded this year, are discussed in this section. As always, if a service or professional role is still available but the costs are out-of-date, current salary information and inflators are employed to adjust the costs to the present year. When a schema is ten or more years old, no recent data have been found, and the service is no longer relevant, we delete the schema from the publication until new research or other data are available. Previous articles and schemata which are no longer found in this edition are listed at the end of the report and these can still be downloaded online if required. Guest editorial and articles Economics and Cochrane and Campbell methods: the role of unit costs (pages 7-14) The guest editorial this year has been written by Ian Shemilt and Miranda Mugford of the influential Campbell & Cochrane Economics Methods Group. They discuss how systematic reviews and economic evaluations of interventions inform health and social care policy and practice in the UK and explore how unit cost data fit into the overall picture. Costs of support organisations for people with direct payments and personal budgets (pages 15-19) As personal budgets are implemented it is expected that many more service users will choose to take their personal budget as a direct payment and should have access to direct payments support (DPS). In this article Vanessa Davey presents the first comprehensive calculation of DPS unit costs using a method which reflects resource utilisation and other costs such as those related to operating a scheme in a rural area.

12 2 Unit Costs of Health and Social Care 2009 The cost of services for people with dementia (pages 21-25) Following the publication of the first ever National Dementia Strategy in February 2009 (Department of Health, 2009a) and the subsequent implementation plan (Department of Health, 2009b), Jennifer Beecham and Raphael Wittenberg have drawn on previous work in order to cost the proposed services for people with dementia. The National Dementia Strategy sets out initiatives designed to make the lives of people with dementia, their carers and families better and more fulfilled. Social Care Institute for Excellence s (SCIE) work on economics and the importance of valuing unpaid care (pages 27-33). Costing unpaid care is fundamental to economic evaluations in social welfare in order to form a reliable picture of the true costs and benefits of an intervention. In this article Jennifer Francis and David McDaid outline the importance of valuing unpaid care, and identify the issues involved in doing so. They discuss the different methods which can be adopted to value the principal element of caregiving: the cost of carers time. Improvements and new information Expert Patients Programme This year, following consultation with Gerry Richardson at the Centre for Health Economics (CHE) at the University of York, we have included a schema on the Expert Patients Programme (EPP) which provides the cost per participant for 2008/09. This programme is a lay-led self-management programme specifically for people living with long-term conditions. Having been successfully piloted, the Expert Patients Programme currently offers around 12,000 course places a year and is now being made available through primary care trusts and partner organisations. Services for people with learning disabilities The information used in previous years for some of the schemata in this section is now more than ten years old (Emerson and colleagues, 1999) and has been replaced with new estimates. This year we have drawn on a study funded by the Wellcome Trust and carried out by Felce and colleagues in 2005 in order to produce unit costs for group homes (4.1), fully staffed living settings (4.3) and semi-independent living settings (4.5). As no new estimates are available for village communities (4.2) and supported living schemes (4.4), but the services are still current, we have continued to include them in this report using the same Emerson study. However, following policy in the Government White Papers Valuing People (2001) and Our Health, Our Care, Our Say (2006), we have excluded the schema this year on NHS residential campus provision (previously 4.3) as the NHS, with its partners, is required to replace these by 2010 with appropriate housing and support using new alliances and approaches. Unpaid care This year, as well as an article on unpaid care discussed above, we have included new information in section 6 on a variety of values which can be used in order to estimate the cost of carers time. This schema (6.10) will remain in the report every year and will be updated using either new information that becomes available or the appropriate inflators.

13 Unit Costs of Health and Social Care Salaries of NHS staff In previous volumes, the salary information which is generated using a sample of organisations from the Electronic Staff Record (ESR) Data Warehouse, which records payments made to staff in the NHS, has been labelled as experimental. This was to allow time to remove the effect of sampling bias while the ESR was rolled out to all NHS organisations. Now the information provided by the Information Centre makes use of data from all NHS organisations taking up ESR, with the exception of two Foundation Trusts which are yet to join. The experimental label has therefore been removed and this year all NHS salaries have been taken from the NHS staff earnings estimates (January-March 2009) provided by the Information Centre. Salaries of local authority staff In last year s publication, it was reported that the National Minimum Dataset for Social Care (NMDS-SC) had been piloted across local government and it was hoped that this year we could use this information in the Unit Costs report. Unfortunately, because salary information has been received for social workers and social work assistants from a limited number of authorities, Skills for Care have advised that this year we should continue to use the Earnings Survey carried out by Local Government Analysis and Research (LGAR) which is based on information provided by 46 local authorities. We have, however, used information from the National Minimum Dataset for Social Care for local authority home care workers, which is based on a survey of 4,795 home care workers, of which 1,795 are local authority home care workers. No comparative information has been collected this year by the LGAR on home care workers. Unit costs for the independent sector Following the publication of the survey Adult Social Services Expenditure Survey (Local Government Association, 2009), this year we have included for the first time the unit costs for social care services (including private nursing homes for older people and residential homes for people with physical disabilities and for people with mental health problems) provided by the independent sector. These costs have been included in the relevant sections according to client group. Hospital doctors In this section this year, on advice from the Department of Health, we have included an additional group of doctors (registrars) and also the Associate Specialist in the hospital doctor section. Superannuation Each year we carry out a survey of 20 authorities for information on the local authority contributions to superannuation. Last year the rate had increased to 17.7 per cent from 15.9 per cent. This year the rate has increased to 18.6 per cent.

14 4 Unit Costs of Health and Social Care 2009 Other information Paramedic and emergency ambulance services The schema for this service (previously in the hospital and other services section) has been excluded from this edition of the Unit Costs report following discussions with the Department of Health. This costing was carried out in the mid-1990s and has been uprated in previous volumes ever since. It is now no longer representative of the paramedic and emergency ambulance services, but we hope to reintroduce this schema following work being carried out on Payment by Results (PbR) for ambulance services. This work is currently in the pilot phase ( ViewResource.aspx?resID=260848). Information on paramedic services can now be found in 6.1 and more detail can be found in the Department of Health s Reference Costs ( DH_098945). Personal Social Services Expenditure Return Every year, the NHS Information Centre for health and social care (IC) reports on local authority income, expenditure and activity of key services in the PSS EX1. In 2008, the Department of Health published the document Improved Reporting of Adult Social Care Finance and Activity Data which provides information on planned changes to the PSS EX1 return. Following these recommendations, all changes made to PSS EX1 for 2008/09 are provided in information and guidance documents produced by the IC (The Information Centre, 2009). Social worker qualification costs Development work in collaboration with the Social Care Workforce Research Unit has been carried out this year on the cost of qualifying social workers. This has involved providing an estimate of the expected working life of social workers and researching the investment costs of training social workers. This work will be reported in next year s volume. Finally, we would like to thank all those who have called or ed to comment on estimates or to draw our attention to new material available. This information is invaluable and will help to ensure that we are providing information which is as up-to-date as possible. References Department of Health (2008) Improved Reporting of Adult Social Care Finance and Activity Data, Revisions to the PSS EX1 Return, Department of Health, London, dh_digitalassets/@dh/@en/documents/digitalasset/dh_ pdf. Department of Health (2009a) National Dementia Strategy, Department of Health, London, Department of Health (2009b) Living Well With Dementia: A National Dementia Strategy Implementation Plan, Department of Health, London, PublicationsPolicyAndGuidance/DH_ Emerson, E., Robertson, J., Gregory, N., Hatton, C., Kessissoglou, S., Hallam, A., Knapp, M., Järbrink, K. & Netten, A. (1999) Quality and Costs of Residential Supports for People with Learning Disabilities: A Comparative Analysis of Quality and Costs in Village Communities, Residential Campuses and Dispersed Housing Schemes, Hester Adrian Research Centre, University of Manchester, Manchester.

15 Unit Costs of Health and Social Care Information Centre (2009) Information and Guidance for the Personal Social Services Expenditure Return (PSS EX1), Leeds, PSS%20EX% %20Guidance%20notes.pdf Local Government Association (2009) Adult Social Services Expenditure Survey ,

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17 Guest Editorial Economics and Cochrane and Campbell methods: the role of unit costs Ian Shemilt 1,2 and Miranda Mugford 1,2 Introduction Systematic reviews and economic evaluations of interventions 3 have become two important, sometimes integrated, components of the research evidence-base to inform health and social care policy and practice in the UK (National Institute for Health and Clinical Excellence (NICE), 2008, 2009; Coren & Fisher, 2006; Francis, 2009). This development has paralleled the emergence of the Cochrane Collaboration (C1) 4 and (later) the Campbell Collaboration (C2) 5 as two counterpart global organisations that aim to help people make well-informed policy, practice and consumer decisions by preparing and maintaining world libraries of systematic reviews of reliable and up-to-date evidence on the effects and other aspects of interventions. C1 and C2 reviews cover a wide range of health care (C1), social care (C1 and C2), education (C2) and criminal justice (C2) topics, and are intended for an international audience of end-users. Since their inception, both collaborations have recognised that, faced with limited resources and constrained budgets, decision-makers and those who support them often need to consider not only the balance between the beneficial and adverse effects of interventions on health and well-being, but also their impact on resource use and costs, and ultimately whether their implementation is likely to lead to a more efficient use of resources. This recognition led to the establishment of the Campbell & Cochrane Economics Methods Group (CCEMG), 6 which aims to develop and support the application of internationally relevant but locally useful economic methodologies in C1 and C2 reviews. Some of the methods concern how to incorporate critical summaries of economic evidence collected from published and unpublished intervention studies into the reviews themselves, in order 1 Campbell & Cochrane Economics Methods Group. 2 Health Economics Group, School of Medicine, Health Policy & Practice, University of East Anglia. 3 The term intervention is used here to refer to any health, social care/welfare, education or criminal justice technology, programme, service or policy. The term intervention is used interchangeably with the term technology throughout this editorial. 4 For further information visit the C1 website at 5 For further information visit the C2 website at 6 For further information visit the CCEMG website at

18 8 Unit Costs of Health and Social Care 2009 to provide additional, useful policy insights. Other methods focus on making the reviews as useful as possible to inform evidence-based decision-making in specific settings. This may be achieved through development of modules incorporating context-specific economic analysis and commentary as front-ends to published C1 and C2 reviews. It could also be achieved through the development of economic and effectiveness components of reviews to facilitate their use in subsequent technology assessment, appraisal and practice guideline development processes and/or economic evaluations, conducted in the UK and other jurisdictions. These two sets of methodologies are not mutually exclusive. The objective of this editorial is to explore how unit cost data fit into this overall picture. Critical summaries of economic evidence C1 and C2 intervention reviews provide comparative assessments of the effects of alternative interventions in terms of pre-specified sets of clinically, socially and/or consumer (e.g. patient) important outcome measures. This is achieved through systematic identification, appraisal, synthesis and summary of evidence collected from reliable primary studies, focusing on well-designed studies comparing pre-specified experimental intervention(s) with pre-specified counterfactual(s) (Higgins & Green, 2008). If appropriate, synthesis may include use of meta-analysis to combine outcome data collected from two or more primary studies in order to produce weighted average estimates of incremental effect-sizes that are potentially more precise 7 than estimates produced by a single study alone, and with increased power to detect a real effect 8 (Deeks et al., 2008). Although not yet a core methodological requirement of C1 and C2 reviews, many reviews already extend their focus to include coverage of economic issues (Shemilt & Mugford, 2009; Shemilt et al., 2006). At one end of a continuum of the degree of economic input to these reviews, their economic components are limited to brief background descriptions of the economic burden that the health condition, social or behavioural problem addressed by the compared interventions places on (for example) health and social care systems, individuals or society. The background may also describe potential impacts the experimental intervention(s) may have, compared to the counterfactual(s), on resource utilisation and/or costs incurred by health and social care systems, individuals or society. At the other end of the continuum, some C1 and C2 reviews aim to develop critical summaries of economic evidence collected from included studies. CCEMG has published methods guidance for authors of C1 and C2 reviews to inform the conduct of optional stages of research that would place the economic components of the review at different levels on this continuum (Shemilt et al., 2008a, 2008b). As with the parallel review of evidence on intervention effects, a critical summary of economic evidence requires systematic identification, appraisal, synthesis and summary of evidence collected from reliable primary intervention studies. Intervention studies that may have collected useful evidence on economic aspects of alternative interventions include, inter alia, comparative effectiveness research studies and full or partial economic evaluations (e.g. cost-effectiveness analyses or cost-analyses). Some of these may report different aspects of the same research study, as is sometimes the case with economic evaluations conducted alongside randomised controlled trials. 7 The estimation of an intervention effect can be improved when it is based on more information (Deeks et al., 2008). 8 Power is the chance of detecting a real effect as statistically significant if it exists. Many individual studies are too small to detect small effects, but when several are combined there is a higher chance of detecting an effect (Deeks et al., 2008).

19 Unit Costs of Health and Social Care On one level, measures of resource use, costs and cost-effectiveness can be treated as additional effect outcomes in a C1 or C2 review, alongside other clinically, socially and/or consumer (e.g. patient) important outcomes (Shemilt et al., 2008a, 2008b). However, levels of resource use, costs and (by extension) estimates of the cost-effectiveness associated with interventions are highly likely to vary systematically between countries, or in different regional or service settings, and over time (Anderson, in press). Such variations are most commonly attributed to differences in unit costs and currencies between settings, and over time due to inflation (Sculpher et al., 2004). But other differences in features of the intervention and/or decision context such as clinical or professional behaviours, attitudes and practices, practice settings, levels of consumer compliance or valuations of outcomes, economies of scale, financial incentives, current treatment or service comparators, alternative uses of resources (opportunity costs), as well as complex interactions between all of the above factors also drive such variations (Anderson et al., in press; Lessard & Birch, in press, Shemilt et al., 2008a). Therefore, unlike the parallel review of evidence on intervention effects, the aim of a critical summary of economic evidence is not only to explore the nature of summary estimates of (in this case) the incremental resource use, costs and/or cost-effectiveness of the compared interventions (Shemilt et al., 2008a, 2008b). Rather, the principal aim is to utilise the available evidence to summarise what is known from different studies, conducted in different settings and at different times, about economics aspects of interventions, in order to: Help end-users to understand key production factors, demand factors, and economic trade-offs between alternative interventions and thus the structure of resource allocation problems they may face and the main parameters that need to be considered (Drummond, 2002). Assess variations between settings in terms of resource use, costs and cost-effectiveness, and potential reasons for these variations, including exploration of how and why particular levels and configurations of resources appear to be related to the levels and types of outcomes observed, and what contextual factors affect these relationships (Anderson et al., in press). Evaluate whether an intervention appears promising, 9 from an economic point of view. A critical summary of economic evidence therefore needs to build upon and refine theories (pre-specified at the protocol stage) and discussion (based on the available evidence) of how the compared interventions are likely to impact on the resources used in their production (input costs), potential changes in the subsequent use of resources (downstream costs/cost savings), and cost-effectiveness, and to set this in an international context (Anderson et al., in press; Gilbody & Petticrew, 1999). Such theories and discussion incorporate and embrace the fundamental a priori premise that the size (and possibly the direction) of estimates of incremental resource use, costs, effects and cost-effectiveness associated with interventions will be different in different settings, depending on the balance and interactions of particular mechanisms, contexts and outcomes operating at different levels within (and outwith) a given system. 9 An intervention may be judged promising, from an economic point of view, under four scenarios: if it appears to have the potential to result in improved outcomes and reduced (or similar) costs; if it appears to have the potential to result in improved outcomes and increased costs, to such an extent that the improvement in outcomes may justify the increase in costs; if it appears to have the potential to result in similar outcomes and reduced costs; or if it appears to have the potential to result in worse outcomes and reduced costs, to such an extent that reduction in costs may justify the worse outcomes. A further condition for an intervention to be judged promising in the context of a C1 or C2 reviews may be that one of the above four scenarios appears to have potential to be applicable in a number of different settings. In practice, the available evidence on resource use, costs and effects often reveals trade-offs between different items of resource use/costs and different outcomes/effects, which may imply that further context-specific analyses are needed to build on the initial judgement.

20 10 Unit Costs of Health and Social Care 2009 Data on unit costs are not utilised directly in critical summaries of economic evidence conducted as part of C1 and C2 reviews, although assessments of sources and variations in unit costs (and any assumptions about resource use that underpin unit costs) between studies and settings are likely to be important in explaining between-study/setting variations in estimates of costs and cost-effectiveness. Front-end economic modules We are not aware of any systematic maps of the evidential relationships between C1 and C2 reviews (including their economic components), technology assessment, appraisal and practice guideline development processes (including their economic components) and economic evaluations or other economic analyses 10 (which may or may not be undertaken as a component of technology assessments) conducted in the UK (or other jurisdictions). What is known is that, in many cases, published C1 and C2 reviews are used to inform technology assessment, appraisal and practice guideline development processes, while in other cases technology assessment reviews conducted in specific jurisdictions are subsequently converted into published Cochrane reviews. If the technology assessment review comes first, this may already include comparative, context-specific analyses of the costs, cost-effectiveness and/or budget impact of interventions, alongside (and incorporating) evidence on intervention effects assembled using a systematic review. 11 There are many examples of (and variations on) this approach in UK health technology assessment reviews (e.g. Pilgrim et al., 2009; McDaid et al., 2009; French et al., 2009). The UK Social Care Institute for Excellence (SCIE) has recently developed a position statement on economic evaluation in social care and sought advice on methods for costing practice guide recommendations, building on established evidence review processes (Francis, 2009; The Matrix Knowledge Group, 2008). If the C1 or C2 review comes first, there is scope to build a bespoke front-end economic module onto the review that includes context-specific economic evidence, tailored for use by specific sets of stakeholders. 12 Taking health and social care as our example and the UK National Health Service (NHS) as the decision-making jurisdiction, the front-end economic module of a C1 review might, at minimum, consist of an economic reading of the clinical effects evidence contained in the review, 13 together with a summary of its economic components, and an assessment of implications for NHS policy and practice. However, the economic module could also include any (or all) of the following: a cost analysis (Drummond et al., 2005), a budget impact analysis (Mauskopf et al., 2007) and a decision model to assess cost-effectiveness (Briggs et al., 2006), 14 each conducted from a UK NHS perspective. The cost analysis component is described below. The budget impact 10 Other forms of economic analysis (i.e. other than full or partial economic evaluations) include, inter alia, budget impact analysis and econometric analysis. 11 Technology assessment reviews may also include a systematic review of existing cost-effectiveness evidence. 12 The precise configuration of each front-end economic module would need to be determined on a case-by-case basis in consultation with all stakeholders. 13 For some reviews, this may be all that is needed, as it may be possible to conclude on the basis of an economic reading of the clinical effects evidence that it is implausible that an intervention is not cost-effective, or possibly cost-saving (e.g. if the incremental levels of per patient resources needed to provide the intervention are very likely to be small and, due to the beneficial effects of the intervention, the incremental per patient reduction in the subsequent utilisation of expensive services is very likely to be high). 14 If it is not judged feasible to develop a decision model to assess cost-effectiveness, another option (applicable to evaluations of certain types of intervention, such as medications) may be to estimate the cost of preventing an event. The cost of preventing an event is an approximate cost-effectiveness statistic calculated by synthesising estimated costs with the epidemiological measure Number needed to treat (NNT) (Maharaj, 2007).

21 Unit Costs of Health and Social Care analysis would build on the cost analysis, 15 while the cost-effectiveness analysis would build on both the cost analysis and the review of intervention effects (including the meta-analysis, if available). 16,17 The cost analysis component of the module would build on both the review of intervention effects and economic components of the review. A cost analysis is a comparative analysis of alternative interventions in terms of their costs only (Drummond et al., 2005). It involves the description, measurement and valuation of changes in resource use that occur as a result of the production (implementation) and effects (outcomes) of the compared interventions. Costs may be differentiated into those associated with resources used in the production of the interventions (resource inputs) and those associated with the influences of the effects of the interventions on subsequent resource or service utilisation (resource consequences). Data on types and/or amounts of resource inputs (description and/or measurement) may be collected from primary studies (either comparative effectiveness research studies 18 or economic evaluations) included in the systematic review, subject to assessments of the applicability of these data to the NHS setting. Depending on the scope and applicability of data available from the review, these may need to be supplemented by analysis of NHS administrative datasets to establish reliable estimates of resource inputs applicable to NHS health and social care practice. Data on types and amounts of resource consequences (description and measurement) may be collected largely from the C1 review, provided the review has collected (and possibly synthesised) outcome data on the range of effects that have important associated resource consequences (e.g. complications of treatment and secondary procedures for a surgical intervention). Unit cost data have a crucial role at the valuation stage of a cost analysis. Essentially, unit costs are applied to each measured amount of resource (e.g. the number of weeks patients stay in a community rehabilitation unit multiplied by the unit cost of the stay, per week). In our example economic module (and depending on the specific resource inputs and resource consequences associated with compared interventions), applicable sources of national UK health and social care unit costs data may include this volume, National Schedule of NHS Reference Costs volumes (Castelli, 2008) and British National Formulary volumes (e.g. British National Formulary, 2009). Other useful UK sources of information and data relating to the calculation of unit costs of health and social care are listed in an appendix (see page 199). Finally, it should be noted that all the components of data we have suggested could potentially be drawn from effectiveness and economics components of C1 and C2 reviews to inform elements of front-end economic modules may also, in principle, be used to inform development of corresponding elements of technology assessment reviews (e.g. assessments of cost-effectiveness and budget impact) or other economic evaluations (e.g. model structure, selection of key parameters, ranges of input data values for key parameters) conducted in specific jurisdictions. 15 Supplemented by applicable demographic and epidemiological data. 16 Supplemented by applicable demographic, epidemiological and (possibly) health state utilities data. 17 If an applicable decision model or other economic evaluation of essentially the same decision problem faced by end-users of the economic module had already been conducted using the same analytic perspective, this may obviate the need to produce some elements of the economic module (or existing analyses could be updated for the module). 18 It may be possible to collect data on resource inputs from comparative effectiveness research studies whether or not the study incorporates any formal economic analysis. CCEMG is developing a resource use data coding tool designed to collect data on resource inputs from such studies, to inform analyses of the implementation costs of interventions (i.e. by applying unit costs to the measured amounts of each resource).

22 12 Unit Costs of Health and Social Care 2009 Conclusions: future challenges and the role of unit cost data One of the key challenges in the ongoing development of economics methods for use in the preparation and maintenance of C1 and C2 reviews and front-end economic modules is the need to establish empirical evidence, through the conduct of methodological research, regarding methodological choices that may be made at each stage of the research process, including the degree to which implementation of specific approaches adds value to reviews, and at what extra cost. It is also essential to continue to build capacity among both systematic reviewers and applied economists to support the production of economics components of reviews, through network development and training activities (training of both systematic reviewers in economics methods and applied economists in systematic review methods). To this end, CCEMG would like to invite applied economists and others working within or across the fields of health and social care, education and criminal justice to contribute to our network and its work. Please or visit the website at for further information. Another challenge is to ensure that economics components of C1 and C2 reviews and bespoke front-end products complement (and do not duplicate) parallel outputs produced within (and outwith) established and emerging technology assessment, appraisal and practice guideline development processes in the UK and elsewhere. In the UK, this requires ongoing collaboration between C1 and C2 (and affiliated researchers and methodologists) and a wide range of UK agencies and stakeholders, such as (at a national-level) the Department of Health, the National Institute for Health and Clinical Excellence, the Health Technology Assessment Programme, SCIE, the Home Office and the Department of Children, Schools and Families. This editorial has described the pivotal function of unit costs data in the production of economic analyses that aim to help decision-makers consider how they should act on evidence from C1 and C2 reviews. In the UK, some key challenges for developers of unit costs data lie in the development of national sources of education and crime and justice unit costs data to sit alongside existing sources of health and social care data, and also in ensuring that the range of available unit costs data within and across these sectors is sufficiently broad to inform economic analyses of the ever-increasing range of new and existing technologies requiring evaluation and re-evaluation. In the context of these challenges, current expansions in UK unit costs research are encouraging. The Personal Social Services Research Unit (PSSRU) is currently developing national unit costs of crime and justice (Netten et al., 2008), and the Centre for Child and Family Research (CCFR) in Loughborough is working on education unit costs as part of a project to develop a children s services cost calculator for UK local authorities. 19 Also, efforts to improve the range and quality of the information contained in current PSSRU Unit Costs volumes are undertaken every year and the publication is kept as current as possible by using the latest data taken from routinely-collected reports, literature and ongoing research. To ensure the accuracy and comprehensiveness of the information, advice is sought from a working group consisting of the Department of Health, PSSRU, the Centre for Health Economics (CHE) at the University of York and the Centre for the Economics of Mental Health (CEMH) in the Institute of Psychiatry, Kings College London. This working group 19 See CCFR s website at for further information, especially the Exploring costs and outcomes research theme.

23 Unit Costs of Health and Social Care meets annually to discuss gaps in the data and to plan future research. It also discusses research in progress so that the unit costs reported always reflect, to a greater or lesser degree, work in progress. Furthermore, every year users of the Unit Costs report are invited to comment on the information and estimates which need improving. In our view, as the range of parallel national public sector unit costs sources and their developers continues to grow, it would be useful to assess whether establishment of a centralised, and possibly international, directory is warranted, to allow researchers and other users of unit cost data to continue to identify gaps in the coverage of public sector unit costs data needed for current and forthcoming analyses in different settings. Note Ian Shemilt and Miranda Mugford are two editors of a forthcoming book, Evidence-based Decisions and Economics: Health care, social welfare, education and criminal justice,tobe published by Wiley-Blackwell in Spring References Anderson, R. (2009) Systematic reviews of economic evaluations: utility or futility?, Health Economics, advance access at doi: /hec Anderson,R.&Shemilt,I.(inpress)Chapter3:Therole of economic perspectives and evidence in systematicreview,ini.shemilt,m.mugford,l.vale,k.marsh&c.donaldson(eds)evidence-based Decisions and Economics: Health care, social welfare, education and criminal justice, Wiley-Blackwell, Oxford. Briggs, A., Sculpher, M. & Claxton, K. (2006) Decision Modelling for Health Economic Evaluation,Oxford University Press, Oxford. British National Formulary (2009) The British National Formulary, Edition 57, Pharmaceutical Press, London. Castelli, A. (2008) Guest editorial: National Schedule of Reference Costs data: Community Care Services, in L. Curtis (ed.) Unit Costs of Health and Social Care 2008, Personal Social Services Research Unit, University of Kent, Canterbury. Coren, E. & Fisher, M. (2006) The Conduct of Systematic Research Reviews for SCIE Knowledge Reviews (Using Knowledge in Social Care: Research Resource 1), Social Care Institute for Excellence (SCIE), available from Deeks, J.J., Higgins, J.P.T. & Altman, D.G. (eds) (2008) Chapter 9: Analysing data and undertaking meta-analyses, in J.P.T. Higgins & S. Green (eds) Cochrane Handbook for Systematic Reviews of Interventions, Version (updated September 2008), The Cochrane Collaboration, available from Drummond, M.F., Sculpher, M.J., Torrance, G.W., O Brien, B.J. & Stoddart, G.L. (2005) Methods for the Economic Evaluation of Health Care Programmes, Third Edition, Oxford University Press, Oxford. Drummond, M. (2002) Evidence-based medicine meets economic evaluation - an agenda for research, in C. Donaldson, M. Mugford & L. Vale (eds) Evidence-Based Health Economics: From Effectiveness to Efficiency in Systematic Reviews, BMJ Books, London. Francis, J. (forthcoming) SCIE s Approach to Economic Evaluation in Social Care, Social Care Institute for Excellence, London. French, B., Leathley, M., Sutton, C., McAdam, J., Thomas, L., Forster, A., Langhorne, P., Price, C., Walker, A. & Watkins, C. (2008) A systematic review of repetitive functional task practice with modelling of resource use, costs and effectiveness, Health Technology Assessment, 12, 30. Gilbody, S.M. & Petticrew, M. (1999) Rational decision-making in mental health: the role of systematic reviews, Journal of Mental Health Policy and Economics, 2, 99, 106. Higgins, J.P.T. & Green, S. (eds) (2008) Cochrane Handbook for Systematic Reviews of Interventions,Version (updated September 2008), The Cochrane Collaboration, available from Lessard, C. & Birch, S. (in press) Chapter 13: Complex problems or simple solutions? Enhancing evidence-based economics to reflect reality, in I. Shemilt,M.Mugford,L.Vale,K.Marsh&C.Donaldson (eds) Evidence, Economics and Decisions: Health Care, Social Welfare, Education and Criminal Justice, Wiley-Blackwell, Oxford. Maharaj, R. (2007) Adding cost to number needed to treat: the COPE statistic, Evidence-Based Medicine, 12,